Author Archives: Jason Schwartz

About Jason Schwartz

Jason Schwartz, LMSW, ACSW, CADC, CCS, is the Clinical Director of Dawn Farm, overseeing treatment services for its two residential treatment sites, sub-acute detox, outpatient treatment services & detention-based juvenile treatment program. Jason is also an adjunct faculty at Eastern Michigan University’s School of Social Work and School of Leadership and Counseling. Jason blogs at www.addictionrecoverynews.com and has been published in Addiction Professional magazine and in a monograph Recovery-oriented Supervision with the Addiction Technology Transfer Center. Jason serves on the advisory boards of Eastern Michigan University’s School of Social Work and School of Leadership and Counseling. Jason also serves as a board member for the Livonia Save Our Youth Task Force, a substance abuse prevention coalition in his home community.

Who’s “we”?

many-and-fewThis article has been forwarded to me by several people. Its author has been writing a series of articles that seek to redefine addiction and recovery.

As Eve Tushnet recently observed, “There’s another narrative, though, which is emerging at sites like The Fix and Substance.com.” This sentence is representative of this alternative narative:

“The addiction field has struggled with defining recovery at least as long and as fiercely as it has with defining addiction: Since we can’t even agree on whether it’s a disease, a learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.”

But are “we” really unable to agree that addiction is a disease? Who’s “we”?

It’s not unlike suggestions that there’s wide disagreement on climate change.

“Since we can’t even agree on whether it’s a diseasea learning disorder or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem.” “. . . just so you know, the consensus has not been met among scientists on this issue. Or that CO2 actually plays a part in this global warming phenomenon as they’ve come up with somehow.”
Health organizations that call addiction a disease or illness:

  • American Society of Addiction Medicine
  • American Medical Association
  • American Psychiatric Association
  • American Hospital Association
  • American Public Health Association
  • National Association of Social Workers
  • American College of Physicians
  • National Institute of Health
  • National Alliance on Mental Illness
  • World Health Organization
Scientific organizations that recognize human caused climate change:

  • American Association for the Advancement of Science
  • American Astronomical Society
  • American Chemical Society
  • American Geophysical Union
  • American Institute of Physics
  • American Meteorological Society
  • American Physical Society
  • Federation of American Scientists
  • Geological Society of America
  • National Center for Atmospheric Research
  • National Oceanic and Atmospheric Administration
Health organizations that dispute the dispute the disease model:

  • I can’t find any. If you have some that are similar in stature to those above, send them to me.
Scientific organizations that dispute human caused climate change:

  • None, according to Wikipedia.

To be sure, there are people who don’t accept the disease model, some very smart people, but they represent a small minority of the experts. (The frequent casting as David vs. Goliath should be a clue.) And, if you look at their arguments, you’ll find other motives (I’m not suggesting nefarious motives) like protecting stigmatizationdefending free will from “attacks”, discrediting AA and advancing psychodynamic approaches, resisting stigma and emphasizing environmental factors.

Attending to some of their concerns makes the disease model and treatment stronger, not weaker. Lots of diseases have failed to do things like adequately acknowledge environmental factors. And, one takeaway from these critics is the importance of being careful about who we characterize as having a disease/disorder explicitly or implicitly (by characterizing them as being in recovery).

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Do we really want to get each other angry?

Bansky-Flower-Brick-Thrower.

Greg Williams says we need to get angry:

It is apparently OK for those family members to angrily demand a better response from the federal government to the current health crisis. But when the addiction recovery community — more than 23 million Americans and their families — gathers to walk, speak and put a face on recovery there doesn’t seem to be much anger at the current state of affairs that is costing us more than 100 American lives every day.

Apparently, anger is a frightening emotion for many in the recovery community. . . .

But how else are we going to collectively move the needle on the current epidemic without using the prime emotion that has been at the forefront of all other advocacy movements in American history

First of all, there are not 23 million Americans in recovery. That kind of truthiness is a good example of some of the risks of activism. It invites skepticism from anyone who looks into that number and invites argument about the definition of addiction and recovery within and and outside of the recovering community.

Floating balloons and celebrating that recovery is possible has been a great start in many communities. But when we look around at other marginalized health populations in history like the HIV/AIDs movement and the disability movement, they get a capital M on “Movement” in our cultural reflections only because they got angry.

. . .

As Stacia Murphy says in my documentary “The Anonymous People” about Marty Mann’s driving force (the first woman to ever achieve long-term recovery in Alcoholics Anonymous who chose to use her personal story publicly for social change), “Advocacy is about anger.”

Well, there are costs to that kind of activism. I have no idea if Marty Mann’s activism contributed to her relapse, but it’s pretty clear that her activism played a big role in her keeping it a secret. Fortunately, she was able to restabilize, but it’s pretty easy to imagine that secret being a big barrier to continuing her recovery.

Looking back on AIDS activism, are we ready for schisms and more radical groups, like ACT UP to become the most visible face of recovery activism? Thinking about the post-MLK/Malcolm X civil rights movement, are we ready for competition to be the face of this cause?

More importantly, what, exactly, are we supposed to get angry about? Williams references discrimination in housing, insurance, employment and access to health services. I’m not sure I know what he’s talking about.

I was reluctant to even comment because I don’t want to be a contrarian or inflict my political fatigue on others. The competition for recognition as an aggrieved class is fierce, ugly and I suspect a lot of us have no interest in recovery being associated with it.

Don’t get me wrong, I’m all for advocacy and I get mad too, but I’m not interested in getting angry, staying angry or getting others angry, especially when those grievances are not concrete and specific.

What comes to mind is this insight from Bill White and Bill Miller’s article on confrontation.

In its etymology, the word “confront” literally means “to come face to face.” In this sense, confronting is a therapeutic goal rather than a counseling style: to help clients come face to face with their present situation, reflect on it, and decide what to do about it. Once confronting is understood as a goal, then the question becomes how best to achieve it. Getting in a person’s face is rarely the best way to help them open up to new perspectives.

Where there are injustices, I’d rather see advocacy that holds a mirror up to the culture that brings it face to face with the injustice and appeals to our shared values to correct the injustice.

I’m not saying it’s the right way or the only way. Maybe it’d be less effective, but it doesn’t demand anger and focusing on individual issues rather than an aggrieved “us” can help avoid the clamoring to be the recognized leader of the cause. (This might be better for the cause and for individuals.) I’m not an expert on the expansion of naloxone, but it’s my impression that success followed policy makers coming face to face with tearful parents who lost their kids who asked (not demanded) legislators to increase access to the drug.

I don’t think we should all take my path and I’m skeptical of certainty. I’ll go with MLK’s sincerity, determination,  faith and conscience, but I’ll take a pass on the anger.

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Michigan increases access to naloxone

hand drowning

We’ve finally increased access to life preservers. Now, how do we get them out of the sea?

It’s official.

The new laws will allow a state resident to obtain a prescription for naloxone, also known by its brand name, Narcan, to immediately reverse the effects of an opiate overdose, whether due to heroin or a prescription drug such as Vicodin or OxyContin. It also requires emergency medical technicians to carry it on the ambulance, something that is already common practice throughout southeast Michigan.

This is very good news.

The next big question is, what comes after the OD?

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Childhood sexual abuse and alcohol problems – TBS

image

A new study (This is a TBS post from 2007) looks for a relationship between childhood sexual abuse (CSA) and alcoholism. It finds that women who experienced CSA have elevated rates of alcohol use at 12-13 years old, but their rates of alcoholism are not any higher than people with similar adolescent alcohol use, though they are higher than the general population.

Two thoughts. First, CSA has been associated with higher rates of addiction. This suggests that CSA may not cause alcoholism, but may lead to early experimentation, which has been associated higher rates of addiction later in life. What’s so interesting about this is that it supports CSA as a pathway to addiction and supports alcohol adolescent alcohol misuse as a response to CSA, but challenges the frequently circulated idea of addiction as self-medication for CSA.

Second, the study didn’t look qualitatively at the CSA. It would have been interesting to see how the following “traumagenic factors” affected alcohol use and dependence: who committed the abuse (was it a trusted adult?); did they report the abuse and where they believed; how invasive was the abuse; how many times were they abused; how many perpetrators were there?

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Bias in the evidence base

evidenceFrom The British Psychological Society’s Research Digest:

In the last few years the social sciences, including psychology, have been taking a good look at themselves. While incidences of fraud hit the headlines, pervasive issues are just as important to address, such as publication bias, the phenomenon where non-significant results never see the light of day thanks to editors rejecting them or savvy researchers recasting their experiments around unexpected results and not reporting the disappointments. Statistical research has shown the extent of this misrepresentation in pockets of social science, such as specific journals, but a new meta-analysis suggests that the problem may infect the entire discipline of psychology.

A team of psychologists based in Salzburg looked at “effect sizes”, which provide a measure of how much experimental variables actually change an outcome. The researchers randomly sampled the PsycINFO database to collect 1000 psychology articles across the discipline published in 2007, and then winnowed the list down to 395 by focusing only on those that used quantitative data to test hypotheses. For each main finding, the researchers extracted or calculated the effect size.

. . .

The authors, led by Anton Kühberger, argue that the literature is thin on modest effect sizes thanks to the non-publication of non-significant findings (rejection by journals would be especially plausible for non-significant smaller studies), and the over-representation of spurious large effects, due to researchers retrospectively constructing their papers around surprising effects that were only stumbled across thanks to inventive statistical methods.

Read the rest here.

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Sublime Recovery vs. Banal Recovery

dialectic3Eve Tushnet offers a really thought provoking discussion of a dialectic involving competing recovery narratives.

First, “sublime” recovery:

In this narrative, addiction and recovery are basically spiritual. Forgive me for drastically oversimplifying a novel I’m loving, but in IJ [Infitite Jest] addiction is often an enslavement of the will or an escape from the self. Recovery is even more insistently spiritual. You recover by giving up and doing as you’re told: Unconditional surrender is the only path to personal peace. If you don’t learn humility through obedience and accept total transformation through surrender to some kind of obscure Higher Power you will destroy yourself and everything you care about.

Then, “banal” recovery:

There’s another narrative, though, which is emerging at sites like The Fix and Substance.com. This is a gradually-coalescing worldview, which typically includes but isn’t limited to “harm reduction” properly understood: ”Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. ”

She contrasts the two narratives in several ways, including their view of authority:

The two narratives have differing views of authority: The 12-Steppy model comes across as authoritarian, and can definitely be used as an excuse for cruelty, but it also has an anarchic respect for the wisdom of ordinary people. It attempts to turn followers into leaders through personal guidance. What I’m (again, super-reductively) calling the harm reduction model is simultaneously much more individualistic, and much more reliant on medical expertise. The expert-layperson hierarchy is in many ways more rigid than the sponsor/sponsee relationship. The harm reduction worldview tries to avoid the problems of class- and education-hierarchies by soliciting as much participation as possible from people on the ground, current drug users. “Nothing about us without us” is a slogan of the harm reduction movement, and one with which I agree… but it’s not a slogan AA ever needed, because AA’s whole genesis and development was by “us,” the alcoholics.

She repeatedly acknowledges that she’s oversimplifying the themes in these narratives, but she does a very interesting job contrasting these narratives and the views within them.

An especially interesting point is around “real” recovery.

The increased prominence of the dramatic 12-step narrative, what I’m calling the narrative of sublime recovery, may make it harder for us to accept that anything else is “real” recovery at all.

Maia Szalavitz, a truly invaluable journalist whose work I’ve recommended here before, recently asked, “Most People With Addiction Simply Grow Out of It–Why Is This Widely Denied?” Part of the answer, I think, is that the growing-out-of-it type of recovery is invisible–and it’s invisible because it’s boring.

I have a couple of reactions. First, that I’m not sure I buy the framing of the the “sublime” narrative as being ascendant.

Second, I’d take a step backward on the this matter. Any addict finding a way out of addiction is something to be celebrated, regardless of the path.

The article she references asks why it’s denied that addicts grow of their addiction. I’ve never heard it disputed that lots of problem users moderate or stop without any professional or informal help. I’ve worked in a fairly traditional treatment program that embraces the “sublime” narrative for more than 20 years and taught social work and chemical dependency classes for more than 10 years and we’ve always discussed the fact that the majority of young people who meet alcohol dependence criteria will “mature out”. We’ve emphasized the importance of careful assessment, looking over an extended period of time for factors like multiple failed attempts to stop or moderate, craving/preoccupation, functional impairment, detoxes with returns problematic use, prior treatment episodes, problems with multiple substances, etc., to try to differentiate between problem use and addiction. This can be especially difficult with young people who have never really tried to quit. The point is that DSM Dependence is not a good proxy for addiction. If you use those criteria for identify addicts you’re going to get A LOT of false positives.

The same problem comes up in recovery advocacy, where we hear the frequent references to 23 million recovering Americans. This number is great for advocacy, but it’s based on surveys that count respondents who report once having “a problem” with drug and alcohol and no longer have a problem. Are these people addicts?

The issue isn’t really about denying their recovery, it’s more about questioning their addiction.

It’s also hard for me to imagine that individuals involved would care much. I get the impression that most of them did not think of themselves as addicts and don’t think of themselves as in recovery.

I don’t deny that there are one-wayers who try to invalidate any path but their own. We see that in all cultures/tribes/organizations. And, I think it’s easy to overstate how much tension actually exists. I don’t hear these conversations among recovering people and I don’t hear much tension around it in professional circles. It’s mostly academics, journalists and activists.

However, where there is tension, I wonder how much of the tension around the “realness” of the growing-out-of-it type of recovery is really about the “realness” of the growing-out-of-it type of addiction.

UPDATE: This isn’t to say I believe that addicts can’t experience “natural remission”. As with any illness, it happens. My question is about the number of addicts who grow out of it.

Related posts:

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Book Review: The Recovering Body

download (3)Jennifer Matesa’s The Recovering Body: Physical and Spiritual Fitness for Living Clean and Sober seeks to provide “a roadmap to creating our own unique approach to physical recovery” and frames “physical fitness as a living amends to self–a transformative gift analogous to the “spiritual fitness” practices worked on in recovery.”

She focuses on five areas, blending her own experiences, other recovering people, empirical research and practical to-do lists. The five areas are:

  • exercise and activity
  • sleep and rest
  • nutrition and fuel
  • sexuality and pleasure
  • meditation and awareness

I see two reasons this book is an important contribution to recovery literature.

First, it’s the first book I’ve seen (not that I’m well read in the area) that places such emphasis on physical wellness and self-care as an important element of recovery within traditional 12 step recovery paths. I’ve seen it addressed as an aside, and I’ve seen it offered as an alternative path, but not as an important element within traditional recovery paths.

As researchers and clinicians search for every tool to give addicts any possible edge as they initiate and maintain their recovery, we’d be wise to take notice. There is a growing body of evidence to support Matesa’s assertions that these are important elements of recovery rather than frivolous and indulgent accessories to treatment and recovery programs.

Second, I am convinced that the future of treatment and recovery programs (All chronic disease management programs, really.) should emphasize a lifestyle medicine as the foundation of care. After all, “recovery as a lifestyle” epitomizes one of the things addiction treatment has gotten really right historically and something the rest of chronic disease care could learn from us.

Despite this, professionally directed treatment that discusses the idea of the “recovery of the whole person” has mostly been lip service. Matesa brings this concept to life and presents holistic recovery as a lifestyle to be cultivated, practiced and maintained. On this front, she’s far ahead of professionals and researchers. The field is not there yet and too often equates recovery with swallowing pills or passively doing what professional helpers direct them to do. Matesa bypasses professionals and speaks directly to recovering people as a peer, calling them to action and offering experiential and empirical truth. That’s radical, in the best sense of the word.

Her writing is very accessible, is not preachy, and unpretentiously conveyed a lot of deep truths that I hadn’t considered but seemed self-evident as soon as I read them.

On a personal note, as someone who only started paying attention to physical fitness after 20 years of sobriety, the book takes a lot of previously disparate pieces of information that I vaguely knew to be true and organizes them into framework that not only deepened my understanding, but offered a concrete path to continue enhancing and securing my own recovery. I highly recommend it.

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